Patient Forms & Policies
At Piedmont Urology, we strive to maintain the highest level of patient care possible. Our goal is to offer the most innovative and least invasive treatment options available while making our patients feel at home and as comfortable as possible. We value the relationships we’ve formed with our existing patients over the years and we look forward to serving you as well.
If you are new patient of Dr. Hettairachchi or are considering becoming a patient, we want to make the process as easy as possible for you. If you have not arranged for your initial appointment, you can do so either by completing the Appointment Request form on this page or by calling us during normal business hours at 336-838-5655.
Please complete the Patient Packet prior to your first appointment.
Please Download the Patient Packet, print it out and fill it out completely, and bring it with you to your first appointment. If you are unable to print this document, please plan on arriving at least 15 minutes prior to your appointment to complete it at our office. Having this paperwork completed prior to your appointment saves time. (You’ll need Adobe Reader to view and print this document.)
Bring your insurance card and photo ID.
In addition, please bring the following:
- Payment or copayment for your visit. Insurance requires us to collect all necessary payments at time of service.
- Physician referral forms if required by insurance.
- Bring all prescription and over-the-counter medications your are currently taking. Actual bottles, etc., are best. If you bring a written list, please include the dose and frequency of each item.
- Any recent imaging studies (x-rays, CT, ultrasounds, bone scans, etc.) in film or electronic format (CD, DVD, DICOM, JPG, etc.). To avoid any delays in your treatment, it is imperative that YOU bring these imaging studies to your office visit.
- Any recent lab / blood / urine test results.
We accept most major health insurance plans including the following:
- Blue Cross / Blue Shield
- United Health
- Medicare Supplements
If you do not see your insurance company or plan listed here, please contact your insurance company to obtain a “preferred provider” list to make sure Piedmont Urology, PLLC is a “participating provider” on your plan prior to scheduling an appointment. Some plans may require you to obtain a referral from your primary care provider prior to seeing a specialist.
If you have a question or concern, please call us during normal business hours at 336-838-5655. After hours, please call Wilkes Regional Medical Center at 336-651-8100 and have the operator page Dr. Hettiarachchi. If you have an emergency, dial 911!